Recommended Treatments for Smoking Cessation
The most effective approach to smoking cessation combines behavioral counseling with pharmacotherapy, specifically combination nicotine replacement therapy (nicotine patch plus short-acting NRT) or varenicline, for a minimum of 12 weeks. 1
First-Line Pharmacotherapy Options
Combination Nicotine Replacement Therapy (NRT)
- Standard dosing: 21 mg patch + short-acting NRT (lozenge/gum/inhaler/nasal spray) for 12 weeks 1, 2
- If 21 mg patch is ineffective, consider increasing to 35 or 42 mg patch 1, 2
- Blood nicotine levels from NRT are significantly less than from smoking cigarettes, making toxicity rare 1
Varenicline
- Initiate 1-2 weeks prior to quit date 2, 3
- Dosing: 0.5 mg once daily on days 1-3, then 0.5 mg twice daily on days 4-7, then 1 mg twice daily for remainder of treatment 3
- Shows highest 6-month abstinence rate (28%) compared to other monotherapies 1, 2
- Contraindicated for patients with brain metastases due to seizure risk 2, 3
- Monitor for neuropsychiatric side effects 2, 3
Bupropion SR
- Can be used with or without NRT for 7-12 weeks 2
- Shows abstinence rates of approximately 19% 1, 2
- Monitor for neuropsychiatric side effects 2, 3
Behavioral Interventions
Recommended Structure
- Minimum of 4 sessions during each 12-week course of pharmacotherapy 1
- First session within first 2-3 weeks of treatment 1
- Session duration: 10-30+ minutes; longer sessions linked to higher success rates 1
- Individual or group therapy, in-person and/or by phone 1
Effective Components
- Problem-solving skills training to identify smoking triggers and develop coping strategies 1
- Social support and encouragement 1
- Motivational interviewing techniques 1
- Brief advice (even 3 minutes) from healthcare providers increases quit rates 1
- Skills for coping with nicotine withdrawal symptoms, which typically peak within 1-2 weeks after quitting 1
Additional Support Options
- Telephone counseling (minimum of 3 calls) 1
- Tailored self-help materials 1
- Referral to smoking cessation quitlines 1
Follow-Up and Monitoring
- In-person or phone follow-up within 2 weeks after starting pharmacotherapy 1
- Additional follow-up at minimum 12-week intervals during therapy 1
- Continue follow-up after completion of therapy 1, 2
- Track smoking reduction attempts; if efforts stall, consider switching pharmacotherapy 1
- Encourage continued therapy through brief slips, as patients who don't quit immediately may quit later 1
Treatment Algorithm for Failed Quit Attempts
- If initial quit attempt fails with combination NRT, switch to varenicline 1, 2
- If initial quit attempt fails with varenicline, switch to combination NRT 1, 2
- Consider extending therapy to 6 months-1 year for continued cessation 1
- Progressively intensify behavioral therapy with referral to specialty care as needed 1
- Consider combination of NRT with bupropion if monotherapy fails 1
Special Considerations
- Patients with cancer have high incidence of depression, anxiety, and stress, which are common causes of relapse 1
- These patients may benefit from specialized smoking cessation programs with staff trained to treat mental health disorders 1
- For pregnant women, behavioral counseling interventions are recommended first-line 1
Common Pitfalls to Avoid
- Providing pharmacotherapy without behavioral support significantly reduces effectiveness 1, 4
- Inadequate dosing or premature discontinuation of therapy reduces success rates 2
- Failure to address psychiatric comorbidities can reduce cessation success 1
- Not offering alternative treatments after failed quit attempts 1, 2
- Neglecting follow-up monitoring and support 1, 2
Effectiveness of Combined Approach
- Combining behavioral and pharmacotherapy interventions increases cessation rates from approximately 8% to 14% compared to minimal intervention 1, 4
- Success rates at 1 year: 3-5% with unaided attempts, 7-16% with behavioral intervention alone, and up to 24% with combined pharmacological treatment and behavioral support 5